Health inspection·July 20, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed (Residents 26). Findings include: Review of facility policy, titled Restorative Nursing Standard with a last revision date of July 23, 2015, and a last review date of November 9, 2022, indicated the following: B. Referral Process 2. Residents will be placed in the program per recommendations of therapy or nursing team members. All residents, as appropriate, after completion of skilled therapy, will have recommendations and referral to restorative program documented in the Therapy Discharge Summary. C. Schedule Residents: 1. Therapy Department team members complete the Restorative Nursing Program form for the specific program and gives form to the Restorative Aide. D. Documentation & Record Keeping 1. A daily schedule will be initiated by the aides to ensure that the interventions and daily documentation are completed. 2. Daily documentation is entered in the Electronic Health Record by the Restorative Aide or designee. Restorative Nursing refers to interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible, and focuses on achieving and maintaining optimal physical, mental, and psychosocial function. Review of Resident 26's clinical record revealed diagnoses that included muscle weakness and contractures (condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) of the right and left knee. Review of Resident 26's care plan revealed no interventions regarding Range of Motion programs. Review of Resident 26's clinical record revealed that they had received Occupational Therapy (OT) from January 5, 2023, through January 18, 2023. Review of facility form, titled Rehab Discharge Program-OT dated January 17, 2023, was marked Restorative and indicated in the section labeled Upper Extremity Range of Motion and Strengthening, Active Range of Motion for fingers, wrists, elbows, and shoulders; three sets of 10 repetitions. Review of Resident 26's clinical record revealed that they had received Physical Therapy (PT) from March 2, 2023, through March 29, 2023. Review of facility form, titled Rehab Discharge Program-PT dated March 29, 2023, was marked Restorative and indicated in the section labeled Lower Extremity Range of Motion and Strengthening, Passive Range of Motion for hips, knees, and ankles; three sets of 10 repetitions. Review of Resident 26's clinical record revealed that they are currently receiving OT, with a start of care date July 11, 2023. During an interview with the Nursing Home Administrator (NHA) on July 18, 2023, at 1:27 PM, the NHA revealed that she could not find any documentation in the point of care documentation for Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395647 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 26 that the Range of Motion programs were provided, as recommended by therapy. She further stated that she could not find where the programs were ever implemented, but that she would look again. During a follow-up interview with the NHA on July 19, 2023, at 8:45 AM, the NHA confirmed that she could not provide any documentation for either of the Range of Motion programs recommended by therapy. She stated that she had no explanation for it. She further indicated that she would expect programs to be implemented as recommended by therapy. 28 Pa. Code 211.11 (a) Resident care plan 28 Pa. Code 211.12(a)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395647 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, observations, record review, and staff and resident interviews, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of 18 residents reviewed (Resident 10). Residents Affected - Few Findings Include: Review of facility policy, titled Oxygen Administration last reviewed November 9, 2022, revealed Procedure 1. Check physician's order for liter flow and method of administration .adjust liter flow as ordered Review of Resident 10's clinical record revealed diagnoses that included obstructive sleep apnea (a sleep-related breathing disorder that causes repeated disruptions in breathing during sleep), multiple sclerosis (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord; symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 10's physician orders revealed an order for oxygen continuous at 2 liters (liters - unit of measure) every shift for shortness of breath, dated November 07, 2020. Review of Resident 10's TAR (Treatment Administration Record - documentation for treatments/medication administered or monitored) revealed documentation to indicate oxygen was running at 2 liters every shift on July 17, 2023, and July 18, 2023. Observation on July 17, 2023, at 8:42 AM, revealed Resident 10's oxygen was running at 4 liters. Observation on July 18, 2023, at 11:08 AM, revealed Resident 10's oxygen was running at 4 liters. Resident 10 then stated, the doctor was supposed to increase my oxygen in the computer, as I prefer it to be at 4 liters. Interview with Employee 3 on July 18, 2023, at 11:09 AM, when the surveyor revealed Resident 10's oxygen was running at 4 liters, Employee 3 stated, I haven't looked at it today. When the surveyor questioned whether Employee 3 had adjusted the oxygen level on July 17th, 2023, or July 18, 2023, Employee 3 replied, I have not changed it yesterday or today. Interview with Employee 3 on July 18, 2023, at 12:54 PM, when the surveyor questioned if she looked at Resident 10's oxygen on July 17, 2023, Employee 10 stated the room was dark and I thought it was running at 2 liters. Review of Resident 10's TAR indicated Employee 3 signed off that Resident 10's oxygen was running at 2 liters on July 17, 2023, at 6:30 AM, and July 18, 2023, at 6:30 AM. Interview with Nursing Home Administrator on July 19, 2023, at 1:46 PM, revealed she would expect physician's orders to be followed. 28 Pa code 211.12(d)(1)(2)-Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395647 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and staff interviews, it was determined that facility failed to ensure pharmaceutical services provide an accurate account for the disposition of uncontrolled medication during the discharge process for one of three discharged residents reviewed (Resident 42). Findings include: Review of facility policy, titled Disposition of Medications last revised June 2023, revealed Upon discontinuation of medication, or resident discharge or death, Disposition of Medications will be documented on the Disposition of Medication Form .Documentation of actual disposition of medication to include the name of the individual disposing the medication, the name of the resident, the name of the medication, the prescription number if applicable, the quantity of medication and the date of disposition. A review of the closed clinical record for Resident 42 on July 19, 2023, revealed that Resident 42 was admitted to the facility on [DATE], and discharged on June 9, 2023. Review of Resident 42's clinical record revealed diagnoses that included hypertension (high blood pressure), hypothyroidism (decreased production of thyroid hormones), and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 42's physician orders revealed that they were not ordered any controlled substances at the time of their death. Orders were only noted for uncontrolled substances. Further review of Resident 42's closed record revealed that there was no documentation of the disposition of their uncontrolled medications. Interview with Employee 8 on July 19, 2023, at 11:00 AM, revealed she completed an audit on closed records and indicated she was unable to find a medication disposition form in Resident 42's record. During an interview with the Nursing Home Administrator (NHA) on July 20, 2023, at 9:01 AM, the NHA revealed she was unable to produce evidence of medication disposition for Resident 42 upon discharge. She further revealed that she would expect the staff to complete the medication disposition form when the medications were destroyed. 28 Pa. Code 211.9(j) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395647 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen, dry storage area, walk-in freezer and refrigerator, and two of two pantries. Findings include: Review of facility policy, titled 3.5 Labeling last reviewed November 9, 2022, revealed Ensure all food items are labeled .Each label must contain the following information: Product name (or a common name or identifying description), Use-by date, Date the product was prepared or opened, Time prepared and team member initials where applicable, Date frozen, if applicable, Date thawed, if applicable. Review of facility policy, titled Storage of Refrigerated & Frozen Foods last reviewed November 9, 2022, revealed Maximum Refrigerated Periods: gravy, broth: up to 7 days; fresh apples: up to 2 weeks; Frozen Shakes Thawed - unopened, 14 days under refrigeration; and Pre-thickened Juices, Water and Beverages Refrigerate after opening and use within 7 days. Observation in the dry storage area on July 17, 2023, at 7:08 AM, revealed: one box of to-go cups and one box of to-go boxes on the floor; one bag of marshmallows not dated; and one box of russet potatoes with a use by date of July 12, 2023. Further observation in the box of potatoes revealed three rotten potatoes. Observation in the main kitchen on July 17, 2023, at 7:18 AM, revealed five colanders stored right side up on a shelf. Observation in the main kitchen reach-in refrigerator on July 17, 2023, at 7:24 AM, revealed one open container of ham base labeled best by July 8, 2023, and one container of feta cheese labeled use by July 13, 2023. Observation in the main kitchen reach-in freezer on July 17, 2023, at 7:31 AM, revealed: one bag of gluten free sauce with a use by date of April 7, 2023; four bags of lasagna without a label or date; half of a loaf of white bread without a date; one bag of everything bagels dated use by February 10, 2023; three dinner rolls without a label or date; one bag of apple cinnamon pancakes with a use by date of January 15, 2023; one pie shell without a date; and one bag of pancakes with a use by date of May 7, 2023. Observation in the walk-in refrigerator on July 17, 2023, at 7:37 AM, revealed: a container of seafood base half-full without an open date; one container of ham base with an open date of February 12, 2023; two pans of mashed potatoes without a date; one container of lemons without a date, further observation of the lemons revealed five rotten lemons; one container of apples with a date of June, 12, 2023; one container of ham base with an open date April 10, 2023; one container of balsamic vinaigrette with a use by date of May 5, 2023; and one bag of [NAME] without a label or date. Observation in the walk-in freezer on July 17, 2023, at 7:52 AM, revealed: one banana pie with a use by date of June 9, 2023; one container of birthday cupcakes with a use by date of May 8, 2023; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395647 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some half a bag of hash browns without a label or date; one bag of frozen corn without a label or date; and one bag of mixed vegetables without a label or date. Observation during initial tour of the [NAME] pantry area refrigerator on July 17, 2023, at 11:04 AM, revealed: one open container of thickened apple juice without a date, and one open container of thickened lemon water without a date. Observation during initial tour of the Arlington pantry area refrigerator on July 17, 2023, at 8:00 AM, revealed: two chocolate shakes without a date; one nutritional drink with a use by date of February 1, 2023; one open container of thickened cranberry juice without a date; and one open container of thickened lemon water without a date. Observation in the freezer revealed four chocolate shakes without a date. Observation in the cabinet revealed four nutritional drinks with a use by date of February 1, 2023. Interview with the Assistant Food Service Director on July 17, 2023, at 8:14 AM, revealed that items should be labeled and dated per policy, and discarded once expired; colanders should be stored upside down; boxes should not be stored on the floor; and food items and kitchen equipment should be stored in accordance with professional standards. Interview with the Nursing Home Administrator on July 19, 2023, at 1:59 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395647 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility documents, facility policy review, and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (second quarter, April - June 2023). Residents Affected - Few Findings include: Review of Quality Assessment and Assurance (QAA) Steering Committee Standard, effective November 28, 2017, revealed that the steering committee, at a minimum, consists of the Nursing Home Administrator (NHA) and two additional community leaders, Director of Nursing or designee, Clinical Quality Manager Infection Preventionist, Medical Director or designee, and a resident/family member. A review of Quality Assurance/Performance Improvement (QAPI) Committee meeting sign-in sheets for the period of September 2022 through June 2023, revealed that all of the following mandatory members were not present at any one meeting held in the second quarter, April - June of 2023: the Director of Nursing services; the Medical Director or his/her designee; at least three other members of the facility's staff, at least one of who must be the Administrator, owner, a board member, or other individual in a leadership role; and the Infection Preventionist. During an interview with the NHA on July 20, 2023, at 8:48 AM, she confirmed that the individuals noted on the sign-in sheets were the only ones in attendance at the corresponding meetings. 28 Pa. Code §201.18(e)(1)(2)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395647 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395647 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spiritrust Lutheran the Village at Gettysburg 1075 Old Harrisburg Road Gettysburg, PA 17325 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on review of the Facility Assessment, personnel files, staff orientation checklist, staff education transcripts, and staff interviews, it was determined that the facility failed to implement and maintain an effective training program for three of five employees reviewed (Employees 5, 6, and 7). Residents Affected - Few Findings include: Review of the Facility Assessment (an evaluation tool for a facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services) last completed on July 10, 2023, indicated in Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies: . 3.4 Staff training/education and competencies: Team members receive centralized orientation after their initial start date. This orientation includes [in part] .dementia training and Relias competencies, prior to on the floor orientation. Relias training at hire includes [in part]: Dementia Management and Communication. (Relias training is a computer-based training program.) Review of Employee 5's (Nurse Aide) personnel file indicated their date of hire was June 14, 2023. Their General Orientation checklist dated June 14, 2023, and their Relias Transcript dated July 19, 2023, revealed no documentation that training on dementia or effective communication was completed. Review of Employee 6's (Licensed Practical Nurse) personnel file indicated their date of hire was June 7, 2023. Their General Orientation Checklist dated June 7, 2023, and their Relias Transcript dated July 19, 2023, revealed no documentation that training on dementia or effective communication was completed. Review of Employee 7's (Registered Nurse) personnel file indicated their date of hire was June 23, 2023. Their General Orientation Checklist dated June 23, 2023, and their Relias Transcript dated July 19, 2023, revealed no documentation that training on dementia was completed. During an interview with Employee 9 (Human Resources Director) on July 19, 2023, at 1:35 PM, revealed that she had reviewed their program and that not all mandatory education modules were added into their virtual online education program when they stopped having in-classroom training days as a result of COVID-19. She confirmed that there was no documentation to show that Employees 5, 6, or 7 completed dementia training, or that Employees 5 and 6 completed effective communication training. During an interview with the Nursing Home Administrator (NHA), Director of Nursing, and Assistant Director of Nursing on July 19, 2023, at 1:50 PM, the NHA confirmed that she would expect all required education to be completed as part of the orientation process. 28 Pa. Code 201.20(a)(b)(d) Staff Development FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395647 If continuation sheet Page 9 of 9